When Queen Elizabeth died last fall, as a geriatrician there was one question I wanted to ask: What were the medical circumstances that cut the nonagenarian Queen’s life “short?” On the death certificate, it turned out, her doctor attested that Queen Elizabeth died of “old age.” This gave me pause: A foundational tenet of geriatrics is that people do not decline or become frail or even die due to “old age”; they face these problems due to illnesses from which they suffer (heart disease, COPD, dementia, diabetes, hypertension, etc.). Even the assumption that kidney function declines with age has been correctly challenged. If the high prevalence of hypertension and diabetes in seniors are factored out, the decline in function is by no means inexorable.
I learned the importance of correctly labeling death certificates way back in 1992. As a brand new and wobbly division chief, I was hauled into a livid VP’s office who said that a 98-year-old patient from our office practice, Reina, had had the cause of death on her death certificate entered as “old age.” Reina’s family was irate, and the VP had assumed it was my patient. It was not — they didn’t bother to look at the signature — but I was asked to go back to the physician in question, hear them out, and possibly obtain an apology or amended death certificate.
Through conversations with the family, I learned that Reina had actually died of “mesenteric collapse,” which I assume referred to mesenteric ischemia and infarcted bowel. Her daughter Helena recounted to me that Reina had been reasonably well and then suddenly developed a stomachache. The exam and scan immediately revealed an acute abdomen and reluctantly, after much prodding from the surgeon, Helena and Reina agreed to surgery. It did not go well post-op, and Reina died soon after. The family had not wanted Reina to have the surgery, and the cursory and inaccurate death certificate only added insult to injury.
Beyond the emotional stakes, death certificates also have legal and financial ramifications. For example, I have seen and cared for dozens and dozens of patients with hip fractures. Often the fractures were due to a “mere” slip and fall, but the patients would die six months later from “hypostatic” pneumonia or an infected wound from reduced mobility. In these instances, it’s often not clear if the manner of death box on the death certificates should be checked “accidental” as opposed to “natural,” or if it should be checked “undetermined” and left to the medical examiner’s office. Notably, if the death is marked “accidental,” there may be a substantial payout for those with an “accidental death” policy rider. Furthermore, if the fall and fracture occurs on hospital or nursing home grounds (or even at a shopping mall), it could be occasion for a negligence lawsuit — which the death certificate can help support or refute.
Despite all the complexities associated with death certificates, I was never instructed as a trainee on how to properly complete one. I believe these days the training is more specific, but in my time, it followed the dictum “see one, do one, teach one,” meaning it was strictly in-the-field training. Given this, I understand why people may be tempted on occasion to write a simple “old age” as cause of death. Indeed, wasn’t that the most common reply when we were asked about losing a grandparent in the 1960s and ‘70s?
I know I have been tempted to use this sort of generalization or euphemism, if only rarely and against my better judgment. After all, about the patient who asks for the cause of her right knee osteoarthritis, it’s still acceptable to answer “wear and tear.” (A clever patient would answer back, “My left knee is just as old as my right and feels fine!”) But other terms are now considered vague and reductive — for example, we can’t write “the dwindles” in good conscience anymore, but that was a term of art in my geriatric office practice or when referring someone to the ER for hydration and evaluation. “FTT” or “failure to thrive,” which originated in the pediatric world, migrated to geriatrics too but now might best be avoided.
Regarding the Queen, perhaps her doctor knew something we didn’t about his eminent patient — or perhaps, having had only her as a patient for years, his skill in filling out death certificates was as meager, and some would say ageist, as Reina’s doctor’s had been. After all, we know that much like Reina (whose name means Queen in Spanish, by the way), the 96-year-old Elizabeth was serving out her duties until the very end; according to custom, she had met with the newly minted Prime Minister Liz Truss just 48 hours before her death, and in the official palace photos was standing erect and engaged.
The debate over what is acceptable on a death certificate dates back to at least the mid nineteenth century. In 1836, per an article in The Conversation, death reports transitioned from church-based to secular (at least in the UK), as a result of the Births and Deaths Registration Act. Not long after, French social scientist Jacques Bertillon penned the eponymous “Bertillon Classification of Causes of Death,” which set down in print the nitty-gritty right and wrongs of ascribing causes of death. Reflecting on this time period, philosopher Ian Hacking has said that “dying of anything other than what was on the official list was ‘illegal, for example, to die of old age’.”
That’s pretty firm language and reflects the intense emotions surrounding this issue. The Conversation article further speculates that we rely in part on death certificates for mortality trends. Moreover, there’s a sense of closure — not to mention genetics — to which families cling in seeing the cause of death. Without that emotional closure, and with something as vague as “old age,” there’s potential for harm. After all, Reina, like the Queen, had crossed into the land of numerical “old age,” but could in no way be defined or delimited by its borders. And so, the next time you're tempted to write “old age,” you may want to think twice — and remember that doing so can be a blow to the late patient and their families.
Have you ever encountered a death certificate that listed "old age" as cause of death? Share your reaction in the comments.
Dr. Schor is a geriatrician specializing in long-term and post-acute care. He was medical director and attending physician at Daughters of Israel for close to 30 years and is now a Senior Medical Director at Optum Health. He is a new grandfather, an avid birder, and lives in Millburn, NJ. Dr. Schor is a 2022–2023 Doximity Op-Med Fellow.
All names and identifying details have been changed to protect patient privacy.
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